Senior Appeal and Denial Specialist
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Job Description
Appeals specialist reviewing healthcare denials, medical necessity, and prior authorizations for Sanford Health. Tracking appeals, supporting compliance, coaching patients, and preparing for audits.
Responsibilities:
- Facilitate the denial and appeal process by reviewing medical records for medical necessity and policy requirements.
- Track appeals through first, second, and subsequent levels and ensure timely filing according to contracts and regulations.
- Administer and prioritize daily tasks while applying Sanford Health Plan policies and regulatory requirements.
- Make case decisions based on product network requirements.
- Contribute to audit and compliance best practices and ensure compliance with government and industry requirements.
- Review clinical-based denials within required timeframes using clinical criteria, payor regulations, and clinical judgment.
- Coach patients and families on proactive care management and help identify and resolve barriers to patient progress.
- Communicate with patients, families, departments, insurance companies, pharmacies, and other healthcare organizations.
- Prepare for external audits and collaborate across healthcare departments.
- Mentor others, share technical expertise, implement medical case management strategies, streamline workflows, and promote understanding of products and services.
Requirements:
- Bachelor's degree required, or a combination of applicable degree completion and applicable experience will be considered.
- Graduate from a nationally accredited nursing program preferred, including CCNE, ACEN, and NLN CNEA.
- Three (3) year's experience required in appeals, medical necessity, or prior authorization process.
- If a graduate of a nursing program, currently licensed with the applicable State Nursing Board and/or possess multistate licensure privileges as required by position.
- Understanding of Sanford Health Plan policies, regulatory requirements, products, benefits, product network requirements, payor regulations, clinical criteria sets, audit practices, and healthcare compliance requirements.
- Experience working with multiple healthcare organizations or providers.
- Ability to handle confidential information and exchange private healthcare information according to regulations.
- Ability to mentor others, adapt communication to different audiences, manage shifting priorities, and apply problem-solving approaches.
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